VA I.G.: 'Comprehensive Healthcare Inspection of Ann Arbor VA Medical Center in Michigan'

WASHINGTON, May 30 -- The Veterans Affairs Inspector General issued the following oversight report (No. 20-01266-117) on April 22, 2021, entitled "Comprehensive Healthcare Inspection of the Ann Arbor VA Medical Center in Michigan":

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Here are excerpts:

Report Overview

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Ann Arbor VA Medical Center, which includes multiple outpatient clinics in Michigan and Ohio. The inspection covers key clinical and administrative processes that are associated with promoting quality care.

Comprehensive healthcare inspections are one element of the OIG's overall efforts to ensure that the nation's veterans receive high-quality and timely VA healthcare services. The inspections are performed approximately every three years for each facility. The OIG selects and evaluates specific areas of focus each year.

The OIG team looks at leadership and organizational risks, and at the time of the inspection, focused on the following additional areas:

1. COVID-19 pandemic readiness and response/1

2. Quality, safety, and value

3. Medical staff privileging

4. Medication management (targeting long-term opioid therapy for pain)

5. Mental health (focusing on the suicide prevention program)

6. Care coordination (spotlighting life-sustaining treatment decisions)

7. Women's health (examining comprehensive care)

8. High-risk processes (emphasizing reusable medical equipment)

The unannounced virtual review was conducted at the Ann Arbor VA Medical Center during the week of July 20, 2020. The OIG held interviews and reviewed clinical and administrative processes related to specific areas of focus that affect patient outcomes. Although the OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities limits inspectors' ability to assess all areas of clinical risk. The findings presented in this report are a snapshot of this medical center's performance within the identified focus areas at the time of the OIG review. Although it is difficult to quantify the risk of patient harm, the findings in this report may help this medical center and other Veterans Health Administration (VHA) facilities identify vulnerable areas or conditions that, if properly addressed, could improve patient safety and healthcare quality.

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Inspection Results

The OIG noted opportunities for improvement in several areas reviewed and issued nine recommendations to the Director, Chief of Staff, and Associate Director for Patient Care Services. These opportunities for improvement are briefly described below.

Leadership and Organizational Risks

At the time of the OIG's virtual review, the medical center's leadership team consisted of the Director, Chief of Staff, Associate Director for Patient Care Services, Associate Director, and Assistant Director. Organizational communications and accountability were managed through a committee reporting structure, with Executive Leadership Council oversight of several working groups. The leaders monitor patient safety and care through the Quality, Safety, Value and Risk Committee, which was responsible for tracking and trending quality of care and patient outcomes.

When the team conducted this inspection, the medical center's executive team appeared stable given that all positions were permanently assigned and only the Assistant Director had been in the role for less than a year. The Director, Chief of Staff, and Associate Director had worked together at the medical center since 2018.The Associate Director for Patient Care Services, the most tenured leader, was permanently assigned in January 2007.

The OIG reviewed employee satisfaction survey results and concluded that the leaders appeared to have created a positive workplace environment where employees felt safe bringing forth issues and concerns. For this medical center, aggregate patient survey results were generally better than VHA averages. However, gender-specific survey responses revealed opportunities to improve outpatient experiences in the patient-centered medical home and specialty care settings.

The inspection team also reviewed accreditation agency findings, sentinel events, and disclosures of adverse patient events and did not identify any substantial organizational risk factors./2

The VA Office of Operational Analytics and Reporting adopted the Strategic Analytics for Improvement and Learning Value Model to help define performance expectations within VA with "measures on healthcare quality, employee satisfaction, access to care, and efficiency." Despite noted limitations for identifying all areas of clinical risk, the data are presented as one way to understand the similarities and differences between the top and bottom performers within VHA./3

The executive leaders were generally knowledgeable within their scope of responsibilities about VHA data and/or factors contributing to specific poorly performing medical center and Community Living Center Strategic Analytics for Improvement and Learning measures.4 In

individual interviews, the executive leadership team members were able to speak in depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.

COVID-19 Pandemic Readiness and Response

The results of the OIG's evaluation of the medical center's COVID-19 pandemic readiness and response were compiled and reported with other facilities in a separate publication to provide stakeholders with a more comprehensive picture of regional VHA challenges and ongoing efforts.5

Quality, Safety, and Value

The medical center complied with requirements for a committee responsible for quality, safety, and value oversight functions, patient safety elements, and protected peer reviews. However, the OIG expressed concerns about the Quality, Safety, Value and Risk Committee's improvement action implementation.

Medical Staff Privileging

The medical center met requirements for focused professional practice evaluations. However, the OIG noted weaknesses with ongoing professional practice evaluations and provider exit reviews./6

Medication Management

The OIG observed compliance with some of the elements of expected performance, including pain screening, documented justification for concurrent therapy with benzodiazepines, and use of a multidisciplinary pain management committee to oversee and monitor required quality measures. However, the OIG identified opportunities for improvement with aberrant behavior risk assessments, urine drug testing, informed consent, and patient follow-up after therapy initiation.

Mental Health

The medical center generally complied with the requirements for a suicide prevention coordinator, outreach activities, and patient follow-up. However, the OIG noted concerns with suicide safety plans and annual staff training.

Women's Health

The OIG found compliance with the provision of care and staffing requirements for women's health. However, the OIG identified deficiencies with the Women Veterans Health Committee.

High Risk Processes

The medical center met many of the requirements for the proper operations and management of reusable medical equipment. However, the OIG identified deficiencies with daily cleaning schedules, temperature and humidity monitoring, and staff training.

Conclusion

The OIG conducted a detailed inspection across nine key areas (two nonclinical and seven clinical) and subsequently issued nine recommendations for improvement to the Medical Center Director, Chief of Staff, and Associate Director for Patient Care Services. The number of recommendations should not be used, however, as a gauge for the overall quality of care provided at this medical center. The intent is for medical center leaders to use these recommendations as a road map to help improve operations and clinical care. The recommendations address systems issues as well as other less critical findings that, if not addressed, may eventually interfere with the delivery of quality health care.

Comments

The Veterans Integrated Service Network Director and Medical Center Director agreed with the Comprehensive Healthcare Inspection Program findings and recommendations and provided acceptable improvement plans (see appendixes G and H, pages 65-66, and the responses within the body of the report for the full text of the directors' comments). The OIG will follow up on the planned actions for the open recommendations until they are completed.

JOHN D. DAIGH, JR., M.D., Assistant Inspector General for Healthcare Inspections

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View full report at https://www.va.gov/oig/pubs/VAOIG-20-01266-117.pdf